Of Oysters and Mammograms
“I can’t believe they would put an economic value over the lives of fifteen or more people.” (Statement of a woman whose father died as a result of eating raw oysters that contained a deadly bacteria.)
“Let the rationing begin.” (Rep. David Camp, Ranking Republican on House Ways and Means Committee, responding to U.S. Preventive Services Task Force Report that recommends women delay routine mammograms until age 50).1
Public health takes a beating again.
In the first case, the FDA has had to eat crow. Just last month, the agency trumpeted its “public health” duty to prevent a predictable number of deaths each year by banning the sale of untreated, raw oysters during the summer months. But now the FDA has been shut up by the industry and by too-powerful Louisiana Sen. Mary Landrieu. (She can pretty much get anything she wants, including her own Mardi Gras Float, at least while the health care reform bill is pending.) The agency has slunk away, murmuring something about studying “feasibility and costs.”
In the second case, the jumpy recommendation against routine mammograms (and self-examinations) to detect breast cancer has brought a howl of protests. The objection: “Yes, the test only picks up one cancer case out of every 1,900 — but what if you’re the one?” For opportunists in the Camp camp, this cold-blooded calculation serves as a timely, exploitable proxy for everything that’s wrong about health care reform. Never mind that the proposed legislation does a dismal job at controlling anything — costs or procedures — and that rationing is a fact of life now under managed care.
And when it comes to the battle against breast cancer, stirring outrage is a pink breeze. Anything that would lead to even one more death — period — will be decried as the heartless elevation of population-based data over real lives.
It’s not clear that federal authorities, here representing a population-based, public-health perspective, were right in either case. Perhaps they could have continued efforts at education in the first case (which the FDA said it had tried, without success for a decade), rather than requiring irradiation (which has its own PR cost). In the second case, even public health authorities are split on whether the evidence justifies the new recommendations. At least this was a non-binding task force, easily overcome by political outrage.
There are two issues here. First, public health works best when it can explain and justify its position in a way most reasonable people will find at least defensible. Even then, though, its recommendations — or even coercive steps — can be defeated when other forces (like the oyster lobby or the breast cancer survivor community) are more powerful.
But the more important point — and the one no one wants to discuss — is that we do make safety and efficiency trade-offs, all the time. We couldn’t function without doing so, either in our own lives, or societally. Would routine mammograms be cost-justified if, say, they saved one life in one million? One can always say: “What if you’re that one person?”
- The quote appears in Gail Collins’ reliably insightful and amusing column. ↩